INSTRUCTIONS

Please take your time to complete the questions and please do not panic if there is something you don't quite understand as any further questions you have will be answered during your consultation appointment with Tamara. If you do have any pressing questions, please feel free to call 01264 810004 and we will try to assist you.

This Consultation Form must be completed to validate our Public Liability Insurance and to assess your suitability for cosmetic tattooing procedures. This form will indicate whether you need to seek a doctor's advice before commencing treatment. Please read the questions carefully and answer each one honestly. Please be assured that personal information we receive is treated with utmost confidentiality. Please refer to our Privacy Policy for more details.

How did you hear about us? *

Please use this space to specify 'other' or to tell us who referred you.

Personal Details

Title *

First name *

Last name *

DOB *ie, 02 May 1968

Age: *

Gender *

Occupation

Email *

Mobile Phone *

Home Phone

Address & Postcode *

Emergency Contact *

Primary Phone *

Physician/GP Details

Physician/GP's Name *

Surgery Address & Postcode *

Physician/GP Primary Phone *

The Law

To comply with the Tattooing Act please answer YES or NO to the following questions.

Are you over 18 years of age? *

Are you pregnant or breastfeeding? *

Are you under the influence of alcohol or illegal drugs? *

Do you feel fit and well and able to have the procedure? *Please confirm with the technician on the day of your procedure.

Health Related

Do any of the following apply to you?

Do you have or are you having any injectables, fillers or chemical peels? *

Do you have any allergies or have you experienced any allergic reaction to medicine or products (such as latex, plaster, nickel etc) *

If yes, please elaborate:

Do you have any imminent vacation plans? *

Do you have any keloid scarring? *

Do you suffer from epilepsy and have had a seizure in the last two years? *

Do you suffer from haemophilia? *

Do you knowingly have any infectious diseases? *

Do you knowingly have Hepatitis C? *

Do you suffer from shingles? *

Do you suffer from cold sores, fever blisters or skin disorders in the area to be treated? *

Do you have diabetes? *

Do you have any respiratory problems? *

Do you take blood thinners or anti inflammatories? *

Do you take Antabuse? *

Do you take Roaccutane? *

Do you have high or low blood pressure? *

Do you wear contact lenses or suffer from glaucoma? *

Are you currently taking any other medication? *

If yes, please provide as much details as possible.

Are you five weeks pre or post radiotherapy/chemotherapy treatment? *If yes, medical consent must be given by your doctor.

Are you allergic to any local anaesthetics? *

If yes, please list.

Terms of your treatment.

Please choose YES if you agree or NO if you disagree. Your specialist will check through and ensure you understand and accept these terms.

I understand that Micropigmentation is not medically necessary. *

I understand that Micropigmentation (also known as Cosmetic Tattooing and Semi Permanent Make Up) is an art process, not an exact science, and cannot guarantee you an exact colour result, as colours heal differently in all individuals. The elected colour *Your specialist will explain the expected results prior to the procedure.

I understand the SPMU is a multi treatment process with colour being implanted slowly and carefully over a period of time in a layering process. *You may need to return for additional treatments before your procedure is deemed complete. The payment for additional work – if applicable will be agreed prior to any work commencing. Additional work cannot be carried out for 4-8 weeks, to allow the area to heal fully.

My chosen colour will look much darker when initially implanted but should exfoliate and lighten withing 7/14 days. *

I understand that additional work can not be undertaken for 4-8 weeks in order to allow the skin to fully heal. *

I understand that all colours will fade and alter with time. To keep a fresh appearance, a re-touch procedure will be required every 12-18 months. *Fade is dependent on on age, skin type, medication, colour chosen and sun exposure.

I understand and agree that my specialist will use a Treatment Plan to keep a log of the colours we have chosen, along with my pre and post treatment photographs. *This information will be held securely and confidentially.

I understand that after each treatment the treated area may swell or show redness and, in some cases, bruising. *My specialist will recommend how to take care of this. I may experience some discomfort but my specialist will reassure me throughout and will endeavour to make me feel comfortable.

I understand that if I have an MRI or CAT scan I must tell the radiologist that I have had an SPMU procedure. *I may experience a slight tingling in the treated area.

I have read the aftercare advice and I understand that I must adhere strictly to these instructions. *

My specialist will discuss likely outcomes with me and recommended a treatment plan prior to any work being agreed and undertaken. *

Lip Procedures. *I understand that should I suffer from Herpes Simplex virus then I may have a cold sore outbreak. I have been recommended a course of Zovirax tablets (or other anti-viral medications) at least five days prior and after the procedure. This should minimise the outbreak or reduce the risk of a serious outbreak altogether.

Titanium Dioxide Disclosure. *Titanium Dioxide is an ingredient present in many colours in minute traces but present in large quantities in lighter formulations and white pigment. Titanium Dioxide is required to make light and vibrant colours. Lasers for permanent hair removal can permanently alter the colour of micropigmentation – which cannot be rectified by having a new procedure. Therefore by having a micropigmentation procedure you must understand and accept that you must inform your laser specialist that you have had a micropigmentation procedure.

Please feel free to insert any notes you wish to in this space. These might be concerns or questions you may wish to raise during your consultation.

Policies

Our SMS Text Service
As a courtesy we may send you an SMS text reminder at least 48 hours prior to your appointment, reminding you of your appointment date and time.
Bodybarn.com can not guarantee this service and impress on you not to rely on this service to remind you of your appointment. You will still be charged for missed appointments even if you do not receive a text reminder.

Cancellation & Bookings Policy
Cancellation policies are never fun, however, much like a Dental surgery we have many bookings. Subsequently, late rescheduling and no shows ultimately results in other clients missing out on appointment opportunities and disrupts the work schedule for the Personal Trainer. We do our very best to accommodate your schedule however, if you fail to turn up for your scheduled appointment as a ‘no show’ you will be charged in full for the services you originally booked for. If applicable your gift voucher will be voided, and any deposit paid will be retained. In order to avoid incurring unnecessary costs and as a matter of common courtesy, we request that you provide us with at least 24 hours notice for all cancellations and/or rescheduling.

Late Arrival
Arriving late will limit the time of your session, lessening its effectiveness and your enjoyment. Your session will end on time so that the next client is not delayed.

Children
In consideration for all our clients and for their safety, children are not permitted in the Personal Training Studio without prior permission from your Personal Trainer, and must be well mannered and supervised at all times whilst in the Personal Training Studio. Parents/ guardians are responsible for the cost of any breakages to bodybarn.com products or property.

Pets
Due to the nature of 'gym' environment, pets are not permitted in the Personal Training Studio with the exception of Guide Dogs.

Treatment Times
Session times include all procedures between arrival and departure from the Studio, ie, consultation, changing of clothing, etc.

Gift Voucher Terms & Conditions
Bodybarn.com gift vouchers may be exchanged for products or services of an equal value or used in part payment to a higher value. No cash can be redeemed for the gift voucher and are non-returnable or transferable. Vouchers will be subject to verification at the time of presentation. Bodybarn.com reserve the right not to accept vouchers that appear to have been altered or tampered with. Vouchers are valid for six calendar months from the purchase date. We reserve the right to change the Terms and Conditions at any time.

This Questionnaire is valid for one year from the date submitted. It is your duty to inform us of any changes to the questionnaire during this period.

Your Consent

Case File Photographs *I consent to photographs being taken before, during and after my procedure which will be kept in my case file. The procedure can not be performed without this consent.

Marketing Photographs *I consent to photographs being taken before, during and after my procedure which may be used within printed and website marketing material for Bodybarn.com purposed. The images are not passed onto third parties or used for any other reason. We appreciate your permission to use photographs for marketing purposes to show future clients the standard of micropigmentation we are able to provide.

Patch Testing for Allergies (a) I understand that a skin test can determine within 24 hours if I will have a reaction to the products, but that it is inconclusive regarding whether I will have an allergic reaction at any time in the future. Therefore I waiver my option to an allergy test and wish to proceed with the treatment.
(b) I have undergone an allergy test prior to my initial treatment and thereby release the technician from any liability related to any allergic reaction to applied pigments or other products used after the procedure, or at a later date.

Treatment Preparation and Aftercare Advice *I confirm that I have read and understand the Treatment Preparation and Aftercare Advice as outlined on the Bodybarn.com website here www.bodybarn-salon.co.uk/aftercare-advice and that I agree to adhere to the advice given.

In submitting this form, you are confirming that you have answered all the questions within truthfully and accurately. I understand the importance of my accurate and complete medical history, and that withholding any medical information may be detrimental to my health and safety during the procedure. I understand that if there is any change in my medical history that it is my responsibility to advice my specialist. I hereby consent to the application of micropigmentation. I have read and understood all the Terms of Treatment and Salon Policies. I hereby give my written consent for my specialist to carry out the treatment of my choice.

Signature *

Ticking the box is the equivalent to a digital signature. We will also require you to sign by hand prior to your treatment.My signature